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There has been notable progress at trust level in putting systems and processes in place and strengthening infection control teams to improve the prevention and control of hospital acquired infection, but the NHS still does not have enough information on the extent and cost of hospital acquired infection. These are the principal findings of a National Audit Office report, examining progress since the NAO’s last report four years ago and against subsequent recommendations by the Public Accounts Committee.

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According to today’s report by head of the NAO Sir John Bourn, progress in preventing infections and reducing their number is dependant on changing staff behaviour, but change continues to be constrained by the lack of data, limited progress in implementing a national mandatory surveillance programme that meets the needs of the NHS, and a lack of evidence of the impact of different intervention strategies.

Robust comparable data (other than on Methicillin Resistant Staphylococcus aureus (MRSA) bloodstream infections, for which mandatory surveillance was introduced in 2001) are not currently available for the NHS in England. This makes it is impossible to quantify with any certainty if there have been any changes in NHS trusts’ infection rates. But the limited information that is available, from the voluntary reporting on surgical site infection surveillance indicates that the degree of improvement has been small, and the mandatory MRSA bloodstream infection surveillance shows that the number of MRSA bloodstream infections has continued to increase.

In its original February 2000 report, the NAO noted that hospital-acquired infections were each year costing the NHS around £1 billion and resulting in at least 5,000 deaths. According to today’s report, these are still the best estimates available, although the Office for National Statistics estimated that MRSA alone was mentioned in 800 death certificates in 2002. Because of the complexities involved in identifying costs, few trusts have attempted to calculate their own costs nor have any attempts been made to refine or validate the cost estimate as stated in the original NAO report. Other countries have also had difficulties in evaluating the economic impact of hospital acquired infection.

Increased demands on infection control teams, with more surveillance and external inspections, has meant that there remains a mismatch between expectations placed on the teams and resources allocated to them. The increased throughput of patients has generally resulted in higher levels of bed occupancy – which complicates good infection control and bed management practices. Some trusts are also concerned about the lack of suitable isolation facilities, the increased frequency with which patients are moved within hospitals and the fact that there are not enough beds to separate elective and trauma patients.

The continuing problem of increasing antibiotic resistance and the emergence of strains of multi-resistant bacteria have increased the complexity of managing and controlling infection. The Department of Health’s mandatory MRSA reporting system has revealed an 8 per cent increase in the number of Staphylococcus aureus bloodstream infections from 17,933 in 2001-02 to 19,311 in 2003-04. Of these, about 40 per cent are MRSA, making the UK’s rate among the worst in Europe.

Even though the profile of hospital acquired infection is increasing and guidelines on the measures required to contain the problem have been published, there continues to be non-compliance with good infection control practices. Hospital-acquired infection is still perceived as a problem for the infection control team alone and not enough staff accept personal responsibility for this issue.

In consequence, many of the barriers to effective infection control practice which the NAO identified in its original report still apply. Considerable improvements could therefore still be made in the following areas: the coverage of education and training in infection control to all groups of staff, particularly doctors; compliance with guidance on issues such as on hand hygiene, catheter care and aseptic technique; antibiotic prescribing in hospitals; hospital cleanliness; and consultation with the infection control team on wider trust activities such as new build projects.

Among the NAO’s recommendations are the following:

  • that the Department of Health work with the Health Protection Agency to expedite development of national mandatory surveillance of hospital-acquired infection, in a way that meets the needs of the NHS and provides robust comparable data;
  • that the Department of Health continue to work with Royal Colleges and professional bodies to ensure that infection control is a key component in undergraduate training, and require induction training in infection control to be made mandatory for all staff;
  • in conjunction with the Health Protection Agency, the Department of Health should commission research on bed management and isolation, and develop evidence based guidance to help trusts balance bed management and infection control requirements;
  • that NHS trusts should require consultation with infection control teams to be a mandatory step in contract tendering procedures for new build projects, and for cleaning, laundry and catering services;
  • that NHS trusts should increase public awareness of and compliance with good infection control practice and encourage their active participation in improving staff and visitor compliance.

"The Department of Health has made important progress in raising the profile in NHS trusts of the control of hospital-acquired infection, culminating in its key publication Winning Ways. However, I am concerned that, four years on from my original report, the NHS still does not have a proper grasp of the extent and cost of hospital-acquired infection in trusts.

"The war against hospital-acquired infection must be pursued on many different fronts: ranging from tackling the factors which inhibit good practice, including a more robust approach to antibiotic prescribing and hospital hygiene, though instituting a system of mandatory surveillance, to persuading all NHS staff to take responsibility for, and contribute towards, effective infection control."

Sir John Bourn


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